title: Bottom up and top down: a comprehensive approach to improve care and strengthen the health system.
abstract: OBJECTIVE
  To describe how building and deploying a network of quality assurance teams can strengthen the health system and the quality of care it delivers.
  
  
  METHODS
  The intervention described consists of a multidisciplinary core team at the national level, trained as trainers, that provides oversight of regional and district quality assurance teams whose purview is to improve the quality of care and operational functions. Quality assurance teams continuously identify and address systemic barriers to the timely delivery of quality services. In parallel, the process involves improving the management capabilities of facility directors and administrators through the use of quality improvement activities that identify and resolve local management and clinical care problems.
  
  
  RESULTS
  A case study of Garissa Province in Kenya shows how this approach was used over a period of several years. National and provincial teams provided systematic oversight, feedback and support. Strong leadership at the district hospital promoted numerous quality improvement strategies that involved local institutional and community problem solving. They achieved greater financial transparency and security, substantially increased utilization of services, decreased response time and raised staff morale and commitment.
  
  
  CONCLUSIONS
  Policies and strategies on paper neither improve care nor the health system unless they are implemented and there is a dedicated trained team to provide oversight. Continuous quality improvement processes at facility level and prompt resolution of system problems lead to increased accountability, quality of care and a stronger health system.
authors.affiliation: Mailman School of Public Health, Columbia University, New York City, NY, USA.
authors.forename: Zafarullah
authors.initials: Z
authors.lastname: Gill
authors.forename: Patricia E
authors.initials: PE
authors.lastname: Bailey
mesh_terms: D003153:Community Health Services / Q000458:organization & administration; D003695:Delivery of Health Care / Q000458:organization & administration*; D006282:Health Personnel / Q000458:organization & administration; D006284:Health Plan Implementation; D006291:Health Policy; D006801:Humans; D007630:Kenya; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D011787:Quality of Health Care / Q000592:standards*